PHIMOSIS: Lost Knowledge Missing In American Medicine

Those who have been keeping their eye on circumcision, circumcision advocates and their alibis, will no doubt be aware that the diagnosis of "phimosis" is far too commonly given as a pretext to circumcise an older child. This is the reason most often cited by parents who claim that circumcision on their child "had to be done." Circumcision is also marketed as prophylaxis for "phimosis" by those who advocate or have to gain from performing the procedure.

It must be asked, how is it that after thousands of years of evolution, human males evolved to be born with a problematic sexual organ?

Is it that the human penis is inherently problematic?

Or is it that there is no real problem, and opportunistic physicians have been successful in characterizing perfectly normal, healthy stages in male genital development as "problematic," when they're actually not?


American and European Physicians Don't Learn The Same Thing
America and Europe are different in many ways. One of the biggest differences between both continents is circumcision and anatomically correct male genitals. Whereas circumcision, particularly the routine circumcision of infant males, is a common, culturally ingrained practice in the United States, it is rare or virtually not practiced in Europe, except among Jews and Muslims.

Perhaps due to Judeo-Christian roots, people in both continents share a taboo surrounding nakedness, so they are unaware of each others' practices. People in Europe often believe that circumcision is limited to religious groups, such as Judaism and Islam, and generally believe that their American counterparts hold male circumcision in the same regard; people in America believe anyone who's anyone is circumcised. It often comes to a shocking surprise to people in either country, when they find out the truth; Americans are surprised that the rest of the English-speaking world does not circumcise, and Europeans are horrified to find out that in America, male newborns are often circumcised.

It is no surprise, then, that American and European physicians hold different views when it comes to male genitals and circumcision. What they learn in medical school concerning male genital development is vastly different; while European physicians are taught to regard unaltered male genitals as nature made them as healthy and normal, American physicians are taught to look at the same genitals as aliens from another planet. While in Europe, physicians are taught to look at the foreskin as an intrinsic part of the male organ, akin to labia in female organs, in the United States, the physicians are taught to treat the presence of a foreskin as a superfluous growth and a liability. Indeed, some hospitals will list the presence of a foreskin alongside other medical problems.

This picture was taken at an American hospital. Notice that being uncircumcised

is a "problem," along side hearing loss and poor growth and weight gain.

To Europeans, penises in American textbooks may appear strange, as they are depicted as circumcised, as if this is they the human penis appears in nature. To Americans, pictures of penises may be "Ew, gross!" The foreskin, if mentioned at all in American textbooks, is often described as "that loose piece of flesh at the end of a penis, which is removed in circumcision." Whereas European textbooks present the penis as-is and moves on, American textbooks must describe various reasons why circumcision is performed, and why parents ought to make a "decision." Circumcision prevents cancer, STDs, makes it easier to clean, and, it prevents phimosis. What good parent wouldn't want to prevent all these problems in their children?

Of course, when comparing world data, it's not entirely clear that circumcision prevents much. Not a single medical organization recommends male circumcision based on any of the claimed "benefits." Circumcised males are still susceptible to cancer and any STD one can name. The latest canard used to justify male infant circumcision is that it prevents HIV transmission. No, scratch that; it's supposed to "reduce the transmission of HIV transmission by 60%," a claim that doesn't really mean much of anything, as even if it were true, even those who promote circumcision as HIV prevention must stress that circumcised males and their partners must continue to wear condoms. (In other words, male circumcision fails.)

The one valid concern is phimosis, an actual physical condition that is exclusive to males with anatomically correct genitalia.

But what precisely *is* phimosis?

Who gets it?

What causes it?

How common is it in actuality?

When and if it is necessary, what treatment options are available?

When is a situation not "phimosis" but a normal stage in development?

I'm writing this blog post to answer these questions and more.

Here, readers will learn what all physicians should be learning in medical school, but is often omitted in American medical curricula. The sources used for this blog post are cited for reference.

The Facts

What is phimosis?

The word "phimosis" originates from the Greek word phimos (φῑμός) which means "muzzle". "Phimosis" is a vague term used to describe any situation where, in intact males, the foreskin cannot be retracted to reveal the glans, or the head of the penis. The term may also refer to clitoral phimosis in women, whereby the clitoral hood cannot be retracted, limiting exposure of the glans clitoridis.

What are the normal stages of development?

At Birth 
Typically, when a baby boy is born, the prepuce is long with a narrow tip.(1)(2) Retraction is not possible in the majority of infants because the narrow tip will not pass over the glans penis. Moreover, it is normal for the inner mucosal surface of the prepuce to be fused with the underlying mucosal surface of the glans, or head of the penis,(1)(2)(4)(5) by means of a membrane called synechia, also known as the balano-preputial membrane or balano-preputial lamina,(1) further preventing retraction. This attachment forms early in fetal development and provides a protective cocoon for the delicate developing glans.(6) It is normal for the foreskin to be non-retractable in infancy and early childhood.(6)

Retraction of the Foreskin In normal development, the foreskin usually separates from the glans and becomes retractable with age.(4) As the infant matures into a boy and the boy into a man, the tip of the prepuce becomes wider, and the shaft of the penis grows, making the tip of the prepuce appear shorter. The membrane that bonds the inner surface of the prepuce with the glans penis spontaneously disintegrates and releases the prepuce to separate from the glans. The prepuce spontaneously becomes retractable.

In order for retraction to occur, the foreskin must have separated from the glans and the opening of the foreskin must have widened to allow it to slip back over the glans. Throughout childhood and adolescence, there is a release of hormones. As hormone levels rise, the fiber-dense tissue of the prepuce is replaced with a more elastic tissue. A boy will begin to explore his genitals as he grows, and as time passes, the elastic tissue will allow the opening of the foreskin to widen. This can happen at any age but it is not common in young boys.

The amount of time it takes for a boy's foreskin to become fully retractable varies from boy to boy; this process can take many years for some boys, and yet minutes for others. In some boys, the foreskin may not be retractable until after puberty.(7)(8)(9) This is an entirely normal stage of development and should not be diagnosed as any kind of "problem." 

When Does Retraction Happen? 
According to the experience of doctors and researchers in cultures where circumcision is uncommon, retraction happens at varying ages, and a non-retractable foreskin rarely requires treatment. Observations from doctors in Denmark, and Japan and other countries indicate that spontaneous loosening usually occurs with increasing maturity.(7)(8)(9)(10)(11)(12)

Non-retractability is considered normal for males up to and including adolescence. The process whereby the foreskin and glans gradually separate may not be complete until the age of 17.(4) A Danish survey (2005) reported that average age of first foreskin retraction is 10.4 years.(13) Marques et al (2005) reported that 99% of boys can retract their foreskins by age 14.(12)(14)(15)(16) One may expect 50% of 10-year-old boys; 90% of 16-year-old boys; and 98-99% of 18 year-old males to have a fully retractable foreskin. Treatment is seldom necessary.

A 1999 study by Cold and Taylor shows that at 6 to 7 years, approximately 60% of the boys had natural adhesions. At 10-11 years, close to 50% of the boys still had adhesions. At 14-15, approximately only 10% of the boys had adhesions. As they approach the age of 17, only a very small percentage of boys will have adhesions. That means that, left uncircumcised, most boys will be able to retract their foreskin before they are 17 years old. 

Foreskin Retraction as Observed in Children in Other Countries 

Jakob Øster, a Danish physician who conducted school examinations, reported his findings on the examination of school-boys in Denmark, where circumcision is rare.(7) Øster (1968) found that the incidence of fusion of the foreskin with the glans penis steadily declines with increasing age and foreskin retractability increases with age.(7)

Kayaba et al. (1996) also investigated the development of foreskin retraction in boys from age 0 to age 15.5, and they also reported increasing retractability with increasing age. Kayaba et al. reported that about only 42% of boys aged 8-10 have fully retractile foreskin, but the percentage increases to 62.9% in boys aged 11-15.(8) Imamura (1997) reported that 77% of boys aged 11-15 had retractile foreskin.

Thorvaldsen and Meyhoff (2005) conducted a survey of 4000 young men in Denmark. They report that the mean age of first foreskin retraction is 10.4 years in Denmark.(13) Non-retractile foreskin is the more common condition until about 10-11 years of age.

Current medical literature indicates that the foreskin is non-retractable in the majority of males until they begin to approach puberty. Until a boy begins to reach sexual maturity, non-retractability of the foreskin is a normal part of growing up.

When is "phimosis" a problem?
Given the empirical facts stated above, it is already mistaken to assume that just because the foreskin cannot be retracted to reveal the head of the penis, a male has some sort of pathological condition. As evidenced by the facts given above, the great majority of male children who have anatomically correct genitals will have foreskins that cannot be retracted, and it is a mistake to assume that all children undergo this transitory "illness" where they can't retract their foreskins, akin to the mumps, measles or chicken pox. Girls do not begin to menstruate until the onset of puberty, and they are not considered to be suffering any sort of medical condition until then.

Non-retractability of the foreskin may pose a problem if it continues well past puberty. Typically the foreskin has dilated to allow retraction as a result of the release of hormones. In a small percentage of males, the production of these hormones is insufficient, and the foreskin fails to dilate, resulting in a condition known as "preputial stenosis," or, a narrow foreskin. This condition may make hygiene and sexual intercourse difficult, if not impossible, but not always. In older men that have bad hygiene habits and who smoke regularly, having a non-retractile foreskin can increase the chances of developing penile cancer.

There is another reason why the foreskin may not be retractable in a male, and that is because he has suffered an infection with balanitis xerotica obliterans, or BXO for short. In this case, the tip of the foreskin is scarred and indurated, and has the histological features of a pathological infection. The foreskin of a male who has suffered an infection with BXO will have developed a fibrotic ring, which makes retraction difficult or impossible. It is this pathologically induced non-retractability which can be correctly termed "phimosis." To differentiate normal stages of development, and even the physiological state of a foreskin which has failed to dilate as a result of lack of hormones, from pathologically-caused non-retractability, doctors have invented the term "true phimosis." It is non-retractability caused by pathological infection with BXO that can be considered an actual problem.

Can phimosis be cured?
It is estimated that 2% of males go their entire lives without their foreskins ever becoming retractable. How this condition can be treated will depend on what the actual problem is. The physiological condition where a foreskin has failed to dilate as the result of a lack of hormones, otherwise known as "preputial stenosis," tends to respond to steroid cream therapy, coupled with stretching exercises and/or stretching devices.

Non-retractability as a result of a BXO infection, however is different, as this is caused by a resulting fibrotic ring at the end of the foreskin, which is scarification that may or may not respond to steroid cream treatment or stretching exercises. It is non-retractability caused by BXO infection that can be genuinely considered a problem which may call for corrective surgery.

It should be noted that non-retractability of the foreskin as a result of BXO infection occurs in less than 1% of males. Additionally, it should be noted that even when a case of "true phimosis" may require surgical correction, it does not always entail a complete removal of the prepuce. There are procedures that can correct phimosis which can preserve the foreskin and its functions. Surgical methods range from the complete removal of the foreskin (circumcision) to more minor operations to relieve foreskin tightness, such as a "dorsal slit" (AKA "superincision") a "ventral slit" (AKA "subterincision") and "preputioplasty."

If treatment should be necessary, it should not be done until after puberty and the male can weigh the therapeutic options and give informed consent.(9)

How should a genuine case of phimosis be diagnosed?
In order to correctly determine that there is a real problem occurring in a male, a learned doctor will begin by ruling a few things out.

If, for example, a child hasn't reached puberty yet, and because non-retractability is common for this age group, the doctor should consider that the child may be experiencing normal stages of development.

If, for example, a child hasn't reached puberty yet, but he was able retract his foreskin previously, it may be probable that the child may have experienced an infection with BXO.

If, for example, an adult male who has already gone through puberty still has a non-retractile foreskin, the doctor needs to determine if this is a physiological problem caused by a lack of hormones (preputial stenosis), or if it is a pathological problem as a result of infection with BXO (AKA "true phimosis").

Because non-retractibility of the foreskin can be both a normal stage of development, and a pathological problem, it can be very easy for doctors to make an inadvertent, or even deliberate misdiagnosis. Particularly in countries like the United States, where circumcision is a perceived norm, and doctors may not be educated in the differences between normal stages of development and phimosis as a pathological condition, it can be very easy for doctors to say that a child is suffering a condition that may require surgical correction, where in fact, there is actually none. 

For a correct diagnosis, a doctor who is knowledgeable about the difference between normal stages of development and non-retractability caused by BXO infection will correctly have the male analyzed for signs of lesions of BXO. Then, and only then, can a doctor properly make the diagnosis that a male child is suffering a medical problem, and that the child may need surgery to correct the problem.

Because non-retractability in adult males is rare, and "true phimosis" (pathologically induced non-retractability) even more rare, there is a high probability that a diagnosis for "phimosis" is actually false, especially in children, where non-retractability of the foreskin is a part of normal development.

Iatrogenically Induced Problems
Problems with the retraction of the foreskin may either be the result of a lack of hormones, the result of an infection with BXO, or, they could be iatrogenically induced. (E.g. actually caused by the doctor himself.)

It has been widely recognized by the medical profession for most of the 20th century that normal male infants have foreskins which are incompletely separated from the epithelium of the glans.(17) The foreskin cannot be retracted without tearing the fusion and adhesions which are commonly present between the inner foreskin and the glans penis in normal stages of development.

In English-language medicine, there is an absence of proper knowledge of the foreskin and its development in the medical curriculum. According to McGregor et al (2005), physicians often have difficulties distinguishing between this normal, natural state of the penis in neonates and pre-pubecent boys and pathological phimosis caused by BXO.(17)(18) Spilsbury et al (2003) suggest that doctors may be likely to confuse the aforementioned conditions with pathological phimosis.(19)

Unaware of the harmless nature of the normal, natural state of the penis in neonates, and the presence of adhesions in infants and pre-pubecent boys, and unaware that this can be damaging, doctors have been known to forcibly attempt to retract the foreskin in healthy, developing children, just to see if it retracts, tearing natural adhesions and/or ripping the foreskin in the process. Furthermore, they have been known to erroneously instruct parents that a child's foreskin needs to be retracted in order to "clean under it," arguing that they will develop infections otherwise.(20)

Premature, forcible retraction of the foreskin is an extremely painful, serious, and potentially permanent injury(17). It can damage the glans and mucous inner tissue of the foreskin. Forcibly retracting a child could result in iatrogenically induced phimosis, where the raw, open wounds of ripped adhesions could heal and fuse together, or where a forcibly dilated foreskin could develop scarification, resulting in a fibrotic ring similar to the one caused by BXO infection. Additionally, this can result in a complication known as "paraphimosis," where the narrow foreskin strangles the penis trapped behind an enlarged glans, thereby necessitating surgical intervention.

It must be noted here that these problems rarely present themselves in countries where circumcision is rare or not practiced. There is simply no epidemic of foreskin problems in countries where male children aren't circumcised. These problems tend to suspiciously present themselves in countries where circumcision is common, and diagnosed by doctors who happen to specialize in child circumcision. Children may have been circumcised to correct "problems" that either never existed, or whom were given their problems by ignorant doctors to begin with.

 It is harmful and misleading to tell parents that a child's foreskin must be forcibly retracted. In children whose foreskins are still adhered to the glans, or where the foreskin has not dilated to allow the glans, this can be a harrowing experience. Forcibly retracting a child's foreskin "to clean under it" is the equivalent of cleaning out a girl's vagina with a pipe cleaner. Surely, a doctor who would instruct parents to clean out their child's vagina would be dismissed as a lunatic. Medical associations advise not to forcibly retract the foreskin of an infant, as this interferes with normal penile development, and may result in scarring or injury.(21)(22).

Camille et al (2002), in their guidance for parents, state that "[t]he foreskin should never be forcibly retracted, as this can cause pain and bleeding and may result in scarring and trouble with natural retraction."(23)

Simpson & Barraclough (1998) state that "[n]o attempt should be made to retract a foreskin in a child unless significant separation of the subpreputial adhesions has occurred. Failure to observe this basic rule may result in tearing with subsequent fibrosis and consequent [iatrogenically induced] phimosis. ..."(24)

The American Academy of Pediatrics cautions parents not to retract their son's foreskin, but suggest that once he reaches puberty, he should retract and gently wash with soap and water.(25) The Royal Australasian College of Physician as well as the Canadian Paediatric Society emphasize that the infant foreskin should be left alone and requires no special care.(26)

Summary
The facts, which are well-documented in medical literature, speak for themselves.

A foreskin that is adhered to the glans and/or will not retract is a normal stage of development in all healthy male children in infancy. The belief that a foreskin that is "tight" and will not retract is a problem in male infants implies that all human male children are born with some kind of birth defect, congenital deformity or genetic anomaly akin to a 6th finger or a cleft.

In the great majority of males, the foreskin separates from the glans and becomes retractable as they approach puberty, without the aid of medical or surgical intervention.

A foreskin that will not retract in older males is rare, and may or may not be a pathological problem. In order to determine the cause of a non-retractile foreskin, a knowledgeable doctor who understands anatomically correct male genitals, the normal stages of development of healthy males, and true pathological problems of male genitalia, must run the correct analyses in order to detect the presence or absence of pathological lesions; then, and only then, can the doctor determine whether the problem can be remedied with conventional medicine or by means of surgical correction.

Even when a genuine case of phimosis that necessitates surgical intervention presents itself, circumcision, or the full excision of the foreskin is not always called for; there are surgical interventions which will correct phimosis while preserving the foreskin and its functions.

Intervention to hasten the retraction of the foreskin in otherwise healthy, prepubescent males may actually cause iatrogenically induced problems. The forced retraction of the foreskin may itself cause non-retractability. Forcibly dilating the foreskin causes scar tissue to form, which may result in a fibrotic ring at the end of the foreskin. Breaking the natural adhesions which occur between the glans and the foreskin during normal stages of development may cause new adhesions to form between the glans and the foreskin, becoming fused as the raw wounds of the broken adhesions heal together. Forcibly pulling back naturally narrow foreskin over the glans in otherwise healthy children may result in paraphimosis, where the narrow foreskin catches behind the glans, preventing the foreskin from returning to its neutral position covering the glans, ironically necessitating the need for surgical intervention.

Conclusion
It is a shame that there is a gap in medical knowledge between the United States and other English-speaking countries. The information presented here is well-documented knowledge that all doctors need to know. This is the information that a doctor needs to be giving to parents of a male child. Anything other than this is misinformation or an outright lie.

American medical curricula is either omitting information, teaching outdated information, if not outright teaching misinformation. Efforts need to be made to bring English-language curriculum on the foreskin, the natural stages of development and genital pathology up to date. Doctors need to educate themselves and stop dispensing erroneous and dangerous advice to parents. They need to learn to differentiate between the normal stages of development in human males, and actual pathological phimosis.

Doctors who diagnose "phimosis" in a perfectly healthy child are either uneducated when it comes to the foreskin and natural stages of development, or may in fact be committing medical fraud, deliberately inventing a misdiagnosis in order to justify surgery in a healthy, non-consenting minor, and/or collecting medicaid funds intended for actually medically necessary surgery.

Until American medicine undergoes this long-needed overhaul, long-term visitors to the United States ought to be warned that doctors in America are often inadvertently, or quite deliberately misinformed about anatomically correct male genital anatomy, and that taking their child to an American-trained doctor could be hazardous to their child's health.

References:
1. Gairdner D. The fate of the foreskin: a study of circumcision. Br Med J 1949;2:1433-7.

2. Spence J. On Circumcision. Lancet 1964;2:902.

3. Deibert GA. The separation of the prepuce in the human penis. Anat Rec 1933;57:387-399.

4.  Øster J. Further fate of the foreskin: incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child 1968;43:200-3.

5. Catzel P. The normal foreskin in the young child. (letter) S Afr Mediense Tysskrif [South Afr Med J] 1982 (13 November 1982) 62:751.

6. Wright J.E. (February 1994). "Further to 'the further fate of the foreskin'". The Medical Journal of Australia 160 (3): 134–5. PMID 8295581. http://www.cirp.org/library/normal/wright2/

7. Øster J. Further fate of the foreskin: Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child (published by the British Medical Association), April 1968. p. 200-202.

8. Kayaba H, Tamura H, Kitajima S, et al. Analysis of shape and retractability of the prepuce in 603 Japanese boys. Journal of Urology, 1996 Nov, V156 N5:1813-1815.

9. Warren JP: NORM UK and the Medical Case against Circumcision. In: Sexual Mutilations: A Human Tragedy; Proceedings of the 4th Intl Symposium on Sexual Mutilations , Denniston GC and Milos MF, Eds. New York, Plenum, 1997) (ISBN 0-306-45589-7)

10. Celsus. De medicina, vol 3. Harvard University Press, Cambridge, p 422

11. Celsus. De medicina, 6.18.2. In: Spencer WG (ed and trans) (1938) Celsus. De medicina, vol 2. Harvard University Press, Cambridge, p 269

12. Hodges FM. Phimosis in antiquity. World J Urol 1999;17(3):133-6.

13. Thorvaldsen MA, Meyhoff H.. Patologisk eller fysiologisk fimose?. Ugeskr Læger. 2005;167(16):1852-62.

14. Marques TC, Sampaio FJ, Favorito LA (2005). "Treatment of phimosis with topical steroids and foreskin anatomy". Int Braz J Urol 31 (4): 370–4; discussion 374. doi:10.1590/S1677-55382005000400012. PMID 16137407. http://www.brazjurol.com.br/july_august_2005/Marques_ing_370_374.htm.

15. Denniston; Hill (October 2010). "Gairdner was wrong". Can Fam Physician 56 (10): 986–987. PMID 20944034. PMC 2954072. http://www.cfp.ca/content/56/10/986.2.long. Retrieved 2014-04-05.

16. Huntley JS, Bourne MC, Munro FD, Wilson-Storey D (September 2003). "Troubles with the foreskin: one hundred consecutive referrals to paediatric surgeons". J R Soc Med 96 (9): 449–451. doi:10.1258/jrsm.96.9.449. PMID 12949201. PMC 539600. http://www.jrsm.org/cgi/pmidlookup?view=long&pmid=12949201.

17. McGregor TB, Pike JG, Leonard MP (April 2005). "Phimosis—a diagnostic dilemma?". Can J Urol 12 (2): 2598–602. PMID 15877942.

18. Metcalfe PD, Elyas R. Foreskin management. Survey of Canadian pediatric urologists. Can Fam Physician 2010;56:e290-5.

19. Spilsbury K, Semmens JB, Wisniewski ZS, Holman CD (February 2003). "Circumcision for phimosis and other medical indications in Western Australian boys". Med. J. Aust. 178 (4): 155–8. PMID 12580740. http://www.mja.com.au/public/issues/178_04_170203/spi10278_fm.html.

20. Osborn LM, Metcalf TJ, Mariani EM. Hygienic care in uncircumcised infants. Pediatrics 1981;67:365-7.

21. "Care of the Uncircumcised Penis". Guide for parents. American Academy of Pediatrics. September 2007. http://www.healthychildren.org/English/ages-stages/baby/bathing-skin-care/Pages/Care-for-an-Uncircumcised-Penis.aspx.

22. "Caring for an uncircumcised penis". Information for parents. Canadian Paediatric Society. July 2012. http://www.caringforkids.cps.ca/handouts/circumcision.

23. Camille CJ, Kuo RL, Wiener JS. Caring for the uncircumcised penis: What parents (and you) need to know. Contemp Pediatr 2002;11:61.

24. Simpson ET, Barraclough P. The management of the paediatric foreskin. Aust Fam Physician 1998;27(5):381-3.

25. American Academy of Pediatrics: Care of the uncircumcised penis, 2007

26. Royal Australasian College of Physicians. (2010) Circumcision of Infant Males.


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